Provider Demographics
NPI:1942554761
Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Other - Org Name:ELLISVILLE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.F.O. / VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:CANIZARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-399-6139
Mailing Address - Street 1:1203 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-2080
Mailing Address - Country:US
Mailing Address - Phone:601-477-8553
Mailing Address - Fax:601-477-9158
Practice Address - Street 1:1203 AVENUE B
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-2080
Practice Address - Country:US
Practice Address - Phone:601-477-8553
Practice Address - Fax:601-477-9158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014135Medicaid